Your situation

Is the advice for you only?

Yes No

If no, who is the second party?

Please answer these questions based on both parties. Where possible, both parties should be together when completing the form.

Have you been in a debt solution before, or are you currently in one?

Yes No

Has a debt advisor made a Breathing Space application on your behalf within the last 12 months?

Yes No

What is your main objective in seeking debt advice?

What happened to make you start struggling with your debts?

Have you reached out to the companies you are in debt with to discuss your situation and to see if they could offer help?

Yes No

If no, is this something you would be willing to do?

Yes No

Have you missed any payments to your creditors? If so, how many months have you been struggling to make the payments?

Is there anything about your personal situation which prevents you from dealing with money or your creditors? (This can relate to any health concerns, that may impact you physically or mentally)

Yes No

Do we have permission to note this on your enquiry?

About you

Where do you currently reside?

How old are you?

What is your relationship status?

What is your residential status?

Does your partner know about your debts?

Do any of your debts have a County Court Judgement (CCJ)?

Have you had any contact from Bailiffs / Enforcement Agents / Sheriffs?

If yes, which company has been contacting you?

Are you self-employed?

Your household

Do you reside with anyone else?

How many children aged under 16 do you live with?

How many children aged 16–18 do you live with?

How many adults do you live with who you are financially responsible for?

Don’t include house-mates, landlords or parents unless you provide for them.

Do you manage your finances with the other people in your household?

Your property

You’ve advised you are a homeowner. Are you the sole owner of this property?

How much is the property worth? (£)

What is the outstanding mortgage on this property? (£)

Have you fallen behind with the payments to your mortgage?

Do you own another property?

Would you be prepared to sell your house or refinance to repay your debts?

Your vehicles

Do you have a car?

What’s the value of the vehicle? (£)

How much is the payment each month? (if lease or finance) (£)

Your debts

Please list each debt you’d like us to help with.

If you do not know the exact amounts, please provide your best estimate.

Type of Debt

Creditor name

Amount (£)

Monthly payment (£)

Your income

Please tell us about all sources of income into your household.

If you select a frequency other than monthly, we will convert it into a monthly amount.

Income type

Amount (£)

Frequency

Notes (optional)

Your expenditure

Now tell us about your regular household spending.

If you select a frequency other than monthly, we will convert it into a monthly amount.

Expense type

Amount (£)

Frequency

Notes (optional)

Your monthly picture

Here’s a summary of your income and expenditure based on what you’ve told us.

Total monthly income

£0.00

Total monthly expenditure

£0.00

Estimated disposable income

£0.00

This would be the amount you could afford to pay into any debt solution.

Your advisor will review these figures with you and adjust any amounts that look too high or too low for your situation.

Other factors

Do you have any savings? (This includes money in bank accounts and investments, but not pensions.)

How much do you have in savings?

Do you currently use an overdraft facility on any of your bank accounts?

Are you expecting a lump sum of more than £1,000 within the next 12 months?

Are you a director, regulated professional (e.g. accountant or solicitor) or a public official?

Are you expecting any of the following in the next 12 months?

How should we contact you?

Name

Best contact phone number

Email address

Any specific days or times for us to avoid contacting you?

I give consent for you to contact me to discuss my tailored debt advice and the options you would recommend.

We will only use your contact details for the purpose of providing you with regulated debt advice, and will not pass this on to any third-party companies. You can view our privacy policy here: Privacy Policy.